COKO Documentation and Record Keeping 3 — Questions and Answers
Question 1: A kinesiologist is documenting a functional movement assessment. Which measurement approach best supports evidence-based documentation?
- Describing movements as 'good' or 'bad' qualitatively
- Using validated, standardized tools with numeric scores (Correct answer)
- Relying solely on client self-report
- Recording only movements the client failed
Correct answer: Using validated, standardized tools with numeric scores
Using validated, standardized assessment tools with numeric scores ensures objectivity, reproducibility, and evidence-based documentation.
Question 2: Which information must be included in every session note to meet COKO documentation standards?
- The client's billing information and insurance details
- Date, client identifier, services provided, and the practitioner's signature (Correct answer)
- A photograph of the client performing exercises
- The client's full medical history
Correct answer: Date, client identifier, services provided, and the practitioner's signature
Every session note must include the date, client identifier, description of services rendered, and the practitioner's signature or credentials.
Question 3: A client discloses during a session that they are being physically abused at home. What is the kinesiologist's documentation obligation?
- Keep the disclosure confidential and document nothing
- Document the disclosure and follow mandatory reporting obligations where applicable (Correct answer)
- Only document it if the client provides written permission
- Refer to a physician and close the client file
Correct answer: Document the disclosure and follow mandatory reporting obligations where applicable
Disclosures of abuse must be documented, and kinesiologists must follow Ontario's mandatory reporting laws where they apply (e.g., children or vulnerable persons).
Question 4: When documenting exercise prescription, which component is LEAST relevant to include?
- Exercise type, sets, reps, and intensity
- Frequency and duration of sessions
- The kinesiologist's personal opinion of the client's effort (Correct answer)
- Progression criteria and modifications made
Correct answer: The kinesiologist's personal opinion of the client's effort
Personal opinions about client effort are subjective and unprofessional; documentation should focus on objective, measurable exercise prescription parameters.
Question 5: A kinesiologist works in an interprofessional setting. When another regulated health professional requests a client's records, what step is required first?
- Share records immediately as all regulated professionals can access them
- Obtain written client consent authorizing the disclosure (Correct answer)
- Obtain verbal consent and note it in the file
- Wait for the client to initiate the transfer themselves
Correct answer: Obtain written client consent authorizing the disclosure
Written client consent is required before sharing records with any other health professional, even in an interprofessional care setting.
Question 6: Which of the following best describes 'informed consent' in the context of kinesiology documentation?
- A form signed at first visit covering all possible future treatments
- A process documenting that the client understands proposed services, risks, and alternatives (Correct answer)
- Permission given verbally that need not be documented
- A legal contract that the kinesiologist keeps without giving the client a copy
Correct answer: A process documenting that the client understands proposed services, risks, and alternatives
Informed consent is an ongoing process documented to confirm the client understands the nature, risks, benefits, and alternatives of proposed services.
Question 7: A client's electronic health record system crashes and session notes are lost. What is the kinesiologist's professional responsibility?
- Recreate notes from memory and backdate them to the original session date
- Document the data loss, recreate notes to the best of ability with a notation explaining the circumstance (Correct answer)
- Do nothing as the data loss was not the kinesiologist's fault
- Contact COKO immediately to report a criminal incident
Correct answer: Document the data loss, recreate notes to the best of ability with a notation explaining the circumstance
When records are lost, the kinesiologist should document the data loss event and reconstruct notes as accurately as possible with a clear notation of the circumstances.
COKO Documentation and Record Keeping 3
A kinesiologist is documenting a functional movement assessment.
Which measurement approach best supports evidence-based documentation?